the best evidence based practice for patient outcomes, what would be the highest priority for your management of this patient on day one?
i. Explaining symptoms, providing reassurance and likelihood of good outcomes
2. ENCOURAGING GRADED RETURN TO WORK AND ACTIVITY
SPONDYLOLYSIS
STRESS FRACTURE OF PI - AGGRAVATED BY EXTENSION INCREASED WITH ACTIVITY DEC WITH REST MAY BE LOCALISED WITH REFERAL
BONE SCAN IS GOLD TEST - PAIN ON EXTENSION
SPONDYLOLISTHESIS
ANTERIOR TRANSLATION OF VERTEBRAE
AGGRAVATED BY FLEXION
USUALLY ASYMP.
INCREASE ACTIVITY
- IF SEVERE, SEVERE PAIN, MUSCLE WEAKNESS AND BLADDER AND BOWEL
SPINAL STENOSIS
Pain increase with walking
- Sx with upright activities and relief with fwd flx
• Gluteal or low extremity pain or fatigue – general ache
• Pain or decrease. Rom in ext.
• Functional impairment in walking distances
• Measure function and quality of life measures
- Posture – slight flx
- +/- neurological signs
RADICULOPATHY
Self reported sensory loss
Dermatomal radiation
Pain coughing, sneezing, straining
Sensory system = altered sensation
Decrease muscle strength/weakness
NSLBP
Low scores on SBST
- Clear and plausible anatomical presentation
- Clear response to aggravating and easing factors
LBP + CENTRALISATION
Higher scores on SBST
- No clear/plausible anatomical location
- exaggerated or inconsistent or unpredictable response to mechanical stressed
Outline two wats in which you could identify risk factors for the patient developing persistent LBP
- Start back screening tool
- Orebro Musculoskeletal Questionnaire
- Fear avoidance behaviours (either questionnaire or questions during interview)
OR SPECIFIC QUESTIONS:
SPECIFIC QUESTIONS IN INTERVIEW
- Extended time off work (or just time off work)
- Inability to modify duties at work
- Co-existing psychological condition (anxiety or depression)
- Passive attitude to rehabilitation
- Avoidance of returning to normal activities
- Current compensation relating to the condition
- Diagnostic language by health professionals
- Previous pathoanatomical explanation or dramatization of health professional
- Experience of conflicting diagnoses
- Catastrophising beliefs or behaviours
- Negative affect
- Imaging – (but only if they mention that they got a poor/pathoanatomical explanation for the imaging findings)
PRIORITY IN EXAM
- Observation and reasoning (lateral shift) – as this will affect management choices – if lateral shift present it will be important to address this with correction in patient management
- Observation/ROM – CAN give individual ROM tests with reasoning of looking for bracing, hypervigilance or fear of moving
- AROM and reasoning (objective measure or to see patients movement pattern or willingness to move)
- Repeated movements and reasoning (to determine directional preference)
- PAIVM if can lye prone and reasoning – (to assess which segment and/or hypomobility)
- Functional tasks – sit to stand, lifting, getting in/out car and reasoning (these are identified as difficult) or a work related task
- Palpation (to assess symptom response)
SPINAL STENOSIS
Subjective: Worse with standing Worse with walking Relieved with positions of flexion Symptoms slowly progressive (0.5 mark) Bilateral leg symptoms (0.5 mark) Objective: Symptoms aggravated with extension Symptoms relieved by flexion Reduced extension ROM
CENTRALISATION VS NON CENTRAL.
Subjective
Consistent aggravating factors
Consistent easing factors
Symptoms localised to a neuro-anatomically plausible distribution
Symptoms not constant (are able to be relieved with movements or positions)
Short duration since symptoms started
Objective
Clear and consistent response to movement tests
Clear and consistent response to palpation/manual examination
No/little hyperalgesia or allodynia
Proportionate levels of pain for tests being performed
NEUROLOGICAL VS NEURDYNAMIC
ASSESS IMPULSE CONDUCTION - IDENTIFY ABDNORMAL CONDUCTION
ASSESS abnormal electrical activity related to mechanical forces, loading or changes that lead to or contribute to symptoms.
IF: you have done a neurological exam you can follow with a neurodynamic exam to gain further information about what manual therapies to use.
Must check for contraindications prior to completing neurodynamic exam
Neural tissue mechanosensitivity contributing to pain state:
- Postural variations - protective - deloading
- Active movements: impairment to movement reinforced with additional manouvres
- Passive movement impairment (SLR, PKB, PNF)
- Nerve trunk hyperalgesia (areas of superficial tenderness)
- Specific areas of local pain or symtpoms (signs at the interface - e.g. Local pain)
- History of recurrent pain states such as recurrent hamstring or calf sprain/tear
MOTOR ASSESSMENT
Static Tests
• Transversus Abdominis with PBU
• Transversus Abdominis with Ultrasound
• Multifidus with Palpation
• Multifidus with Ultrasound
Dynamic
FORWARD LEAN TEST IN SITTING AND/OR STANDING (HIP HINGE)- Ability to keep neutral spine. Observe difficulty that patient has maintaining a neutral spine – try to correct – consider use of TA activation then re-test.
HIP EXTENSION IN PRONE-
Observe movement pattern – lumbar extension, hip extension
ABILITY TO MAINTAIN RELAXED NEUTRAL SPINE THORUGH TASKS-4 point kneel with arm and leg movement, squat, deadlift, plank hold.
LUMBOPELVIC DISSOCIATION
Sitting, 4 point kneel: Cat/camel and quadruped rock
ADDRESS EXTENSION OR FLEXION CONTROL IMPAIRMENT
GENERAL FLOW
INTERVIEW > POSTURAL ASSESS > ACTIVE ASSESS > MANUAL > NEUROLOGICAL, SIJ OR MOTOR ASESMENT
